Monday, February 24, 2014

Hospital patient IT portals are a nice idea, but ...

Patient portals are very much the future of health care. Having easy access to ones’ medical history, diagnoses, and test results, seems like such a natural thing that it’s hard to imagine that only a couple of decades ago medical information was regarded as private for the physician’s eyes only.

Of course, the Internet and a technology revolution have taken this concept to a whole new level. Health care organizations across the nation have been embracing “patient portals” to give patients online access to their records. The federal government’s Meaningful Use policy has provided significant financial incentives to do this.

Among the first to roll out the technology have been the larger multispecialty-type groups that are affiliated with established hospitals. Meaningful Use Stage 2 stipulates that at least 50% of patients must have timely online access to their records, and 5% of patients must transmit electronic health information to their provider. It remains to be seen whether imposing these targets will truly improve patient care (although the concept certainly sets the stage for doing so). But while increasing patient engagement via health care IT is an extremely useful idea for outpatient use, a debate is taking place as to how this should work for inpatient care.

Imagine the future scenario for a hospitalized patient. The doctor walks into the room, and the patient has already seen test results, whether on their own smart device or a flat screen at the end of the bed (now we really are talking about the future). Theoretically, this should make the doctor’s job easier in terms of explanation and implementing a strategy. The medical profession should welcome this model of patient-centeredness. The more engaged and informed the patient, the higher the likelihood of a better outcome.

Nevertheless, some hospital-based physicians are rather uncomfortable with the idea that hospitalized patients will be able to routinely access their results electronically. I must admit that the times I’ve walked into a patient’s room and heard them tell me what that morning’s blood test results are, it has thrown me off a bit! However, this has really only happened a handful of times, probably under half a dozen occasions in my 5-year career in hospital medicine, and typically it’s been a relative rather than the patient who has pulled up the information.

Despite the easy access that many patients now have, uptake of IT portals has been relatively slow when it comes to hospitals. Does the vision of the future involve patients rapidly accessing all of their test results while they are still lying in the hospital bed? Time will tell, but right now a number of barriers exist:• The average age of a hospitalized medical patient is over 70 years old. Simply put, this population isn’t the tech-savvy generation that is comfortable using laptops and smart devices;• People in hospital are often too sick to be scrolling around a screen and digesting complicated information on their own;• Patients may not have ever used a health care IT portal before, and during their hospitalization is not really a good time to learn;• In a significant number of hospitals, the technology isn’t yet available to enable patients to get real-time access to their results;• Low health literacy and patient engagement. There has to be a reasonable baseline understanding of what the different test results mean. A large proportion of patients, especially those from socially disadvantaged backgrounds, are considerably less likely to use and embrace health care technology. And even for more highly educated patients, many seem comfortable putting their complete trust in the doctors and medical staff, and await their results and prognosis to be delivered to them in person rather than access it themselves.

These 5 points are important reasons why IT portal use has been limited among hospitalized patients. Another limitation is that unlike the outpatient setting, getting information in hospital is more complex and presents a whole new set of challenges, particularly when we’re talking about “real time” access to test results. Viewing laboratory values without waiting for the doctor is one thing, but what should the protocol be for getting imaging or pathology results? Or dictated consultation notes? Most of this other information needs to be “electronically signed”, which can take several hours or days. Having this information available to patients before it is reviewed and signed off could potentially result in serious consequences. And on a human level, if the patient was faced with a potentially devastating diagnosis, would it ever be better for them to have access to the result before the doctor had the chance to sit down and talk with them? Even in the ultimate patient-empowerment model, this is a difficult case to argue.

So while the future almost certainly involves hospital patients accessing results themselves, the implications of this need to be considered carefully. As patient portals become more common, health care organizations must decide how best to use them. The question is: how much real-time information is too much?

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

Blog log

Members of the American College of
Physicians contribute posts from their own sites to
ACP Internistand ACP
Hospitalist. Contributors include:

Albert Fuchs,
MD
Albert Fuchs, MD, FACP, graduated from the
University of California, Los Angeles School of Medicine, where he
also did his internal medicine training. Certified by the American
Board of Internal Medicine, Dr. Fuchs spent three years as a
full-time faculty member at UCLA School of Medicine before opening
his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical
Student Member, is a first-year medical student at the OUWB School
of Medicine, charter class of 2015, in Rochester, Mich., from which
she which chronicles her journey through medical training from day
1 of medical school.

Auscultation Ira S. Nash,
MD, FACP, is the senior vice president and executive director of the North Shore-LIJ
Medical Group, and a professor of Cardiology and Population Health at Hofstra North
Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and
Cardiovascular Diseases and was in the private practice of cardiology before joining the
full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and
general internist in the Division of General Internal Medicine at
Johns Hopkins. His research interests include doctor-patient
communication, bioethics, and systematic reviews.

Controversies in Hospital
Infection Prevention
Run by three ACP
Fellows, this blog ponders vexing issues in infection prevention
and control, inside and outside the hospital. Daniel J Diekema, MD,
FACP, practices infectious diseases, clinical microbiology, and
hospital epidemiology in Iowa City, Iowa, splitting time between
seeing patients with infectious diseases, diagnosing infections in
the microbiology laboratory, and trying to prevent infections in
the hospital. Michael B. Edmond, MD, FACP, is a hospital
epidemiologist in Iowa City, IA, with a focus on understanding why
infections occur in the hospital and ways to prevent these
infections, and sees patients in the inpatient and outpatient
settings. Eli N. Perencevich, MD, ACP Member, is an infectious
disease physician and epidemiologist in Iowa City, Iowa, who
studies methods to halt the spread of resistant bacteria in our
hospitals (including novel ways to get everyone to wash their
hands).

Suneel Dhand, MD, ACP Member Suneel Dhand, MD,
ACP Member, is a practicing physician in Massachusetts. He has published numerous
articles in clinical medicine, covering a wide range of specialty areas including;
pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also
authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His
other clinical interests include quality improvement, hospital safety, hospital
utilization, and the use of technology in health care.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more
than a decade and is an Associate Professor of Medicine at an
academic medical center on the East Coast. His time is split
between teaching medical students and residents, and caring for
patients.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the
Internal Medicine Residency and Assistant Dean of Scholarship &
Discovery at the Pritzker School of Medicine for the University of
Chicago. Her education and research focus is on resident duty
hours, patient handoffs, medical professionalism, and quality of
hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings
of medical practice and the complexities of hospital care,
illuminates the emotional and cognitive aspects of caregiving and
decision-making from the perspective of an active primary care
physician, and offers behind-the-scenes portraits of hospital
sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the
University of North Carolina School of Medicine, and the Program
Director for the GI & Hepatology Fellowship Program. He
specializes in diseases of the esophagus, with a strong interest in
the diagnosis and treatment of patients who have
difficult-to-manage esophageal problems such as refractory GERD,
heartburn, and chest pain.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned
authority on nutrition, weight management, and the prevention of
chronic disease, and an internationally recognized leader in
integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of
hematology and medical oncology. His blog is a joint publication
with Gregg Masters, MPH.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics
in medicine, health care news and culture. Her views on medicine
are informed by her past experiences in caring for patients, as a
researcher in cancer immunology, and as a patient who's had breast
cancer.

Mired in MedEd
Alexander M.
Djuricich, MD, FACP, is the Associate Dean for Continuing Medical
Education (CME), and a Program Director in Medicine-Pediatrics at
the Indiana University School of Medicine in Indianapolis, where he
blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice
internist, returns with "volume 2" of his personal musings about
medicine, life, armadillos and Sasquatch at More Musings (of a
Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a
small community hospital in Connecticut. His blog is a series of
musings on medicine, medical care, the health care system and
medical ethics, in no particular order.

The Blog of Paul Sufka
Paul Sufka,
MD, ACP Member, is a board certified rheumatologist in St. Paul,
Minn. He was a chief resident in internal medicine with the
University of Minnesota and then completed his fellowship training
in rheumatology in June 2011 at the University of Minnesota
Department of Rheumatology. His interests include the use of
technology in medicine.

Technology in (Medical)
Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in
education, social media and networking, practice management and
evidence-based medicine tools, personal information and knowledge
management.

Peter A. Lipson,
MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and
teaching physician in Southeast Michigan. The blog, which has been
around in various forms since 2007, offers musings on the
intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice
Boughton, MD, FACP, practiced internal medicine for 20 years before
adopting a career in hospital and primary care medicine as a locum
tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD,
FACP, is an internal medicine physician who has avidly applied
computers to medicine since 1986, when he first wrote medically
oriented computer programs. He is in practice in Tacoma,
Washington.

Other
blogs of note:

American Journal of
Medicine
Also known as the Green Journal, the American Journal of Medicine
publishes original clinical articles of interest to physicians in
internal medicine and its subspecialities, both in academia and
community-based practice.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so
he can create an independent, clinician-reviewed space on the
Internet for physicians to report and comment on the medical news
of the day.

PLoS Blog
The Public Library of Science's open access materials include a
blog.

White Coat
Rants
One of the most popular anonymous blogs written by an emergency
room physician.

ACP Internist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated